Advances in surgery and in critical care have extended therapeutic options as well as the range of patients offered these options. Physiologically brittle patients, including the elderly and chronically ill, are operated upon with increasing frequency using progressively more complex procedures. Nearly all initially survive their operations. When complications threaten patients, the surgical intensive care unit is mobilized to rescue the patient. Although many rescues are successful, some falter and ultimately fail. Problems acknowledging this failure complicate interactions among surgeons, other caregivers, the patient and their loved ones and appear to adversely affect care at the end of these patients' lives. Our long-term objectives are (1) to understand the dynamics and consequences of this interaction; (2) to educate the caregivers regarding these dynamics and their consequences; (3) to test whether this education changes behaviors in ways which improve the interaction and (4) to disseminate our findings to others engaged in related activities. Our premises are that (1) surgeons' management of a dying patient is affected by their perception of accountability for the death and (2) surgeons' exaggerated sense of responsibility for the imminent death adversely affects the experience of other caregivers, patients, their loved ones and the surgeons themselves. We propose to classify, illuminate and (ultimately) manipulate the surgeon's self-perception and others' perception of his accountability for the death. Convergent studies of surgeons, intensivists and critical care nurses in an academic surgical intensive care unit will achieve three specific aims: (1) to investigate, describe, examine and understand how the surgeons' role in care (i.e. as operating surgeon, as non- operating attending physician or as intensivist) affects the rescue imperative; (2) to investigate, describe, examine and understand how the critical care nurses' dual roles, as caregiver and as culture broker, influence one another in negotiating the change in focus from cure to comfort; (3) to investigate, describe, examine and understand how the progress of the negotiation among caregivers and family affects family and friends' perception of their roles and of the well-being of their loved ones. We propose to employ psychological (vignette analyses, microlinguistic analysis); sociological (focus group methodology); and anthropological (ethnography) approaches to achieve these aims. The main products of this initial grant cycle will include a monograph describing the ethnography of death in the surgical intensive care unit; articles in the critical care and surgical literature; and a major multidisciplinary conference to explore appropriate intervention strategies. In the next funding cycle, we will propose the development and dissemination of specific interventions aimed at expanding critical care-based caregivers' understanding of their roles in the dying process so that all can more effectively deliver care to the dying and the bereaved.